ARCHETYPE Examination of body fluid (openEHR-EHR-CLUSTER.exam_body_fluid.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_body_fluid.v0
ConceptExamination of body fluid
DescriptionFindings observed during the examination of body fluid at a body site or from an identified body source, usually as part of a physical examination by a clinician.
UseUse to record a narrative description, structured details and clinical interpretation about findings observed during the examination of any body fluid at a body site or from an identified body source, usually as part of a physical examination by a clinician. This archetype has been specifically designed to be used as the framework for recording details about examination of any body fluid. In order to record examination findings for: - specific types of fluids with unique attributes that need to be recorded, it is intended that a specific CLUSTER archetype for this purpose be nested within the 'Specific findings' SLOT. For example additional details only relevant to clear fluids will be recorded within a specific archetype for this purpose that will effectively extend this generic body fluid archetype; and - multicomponent body fluids such as amniotic fluid that may also contain obvious blood, meconium or pus, it is intended that one instance of this archetype be used to describe the amniotic fluid overall and additional instances of this same archetype will be nested with the 'Specific findings' SLOT to represent each of blood, meconium and pus. Body fluid is a liquid that originates from the human body, and this archetype is intended to support detailed description of: - normal physiological fluids; - physiological fluids that may be altered due to a pathological process; and - fluids generated as part of a pathological process within the body. Examples include, but are not limited to: - Amniotic fluid; - Blood and plasma; - Cerebrospinal fluid; - Discharge; - Urine; - Pus; - Saliva; - Sputum; - Synovial fluid; - Sweat; and - Vomitus. While this archetype will most likely be used in the context of a living subject, it is also appropriate to use in recording autopsy findings. Context about the body site or source will usually be carried in the archetypes in which it is nested, including but not limited to: - in the 'Examination findings' SLOT within many of the CLUSTER.exam family of archetypes and related inspection and palpation archetypes; - in the 'Physical properties' SLOT within the CLUSTER.specimen archetype; - in the 'Additional details' SLOT within the OBSERVATION.urinalysis, the OBSERVATION.fluid_output archetypes; and - within other OBSERVATION or CLUSTER archetypes, where clinically appropriate. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical description' data element.
MisuseNot to be used for recording measurements of fluid volume - use OBSERVATION archetypes for this purpose. For example OBSERVATION.fluid_output. Not to be used to record details about a fluid that does not originate from a body site or from an identified body source. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign. Not to be used to record the results of a urinalysis test - use OBSERVATION.urinalysis. This archetype may be included in the 'Additional details' SLOT to provide additional context to the test result. Not to be used to record the other details about a specimen for use in laboratory testing - use CLUSTER.specimen. Note: despite this exclusion, it is reasonable to use this archetype within the CLUSTER.specimen to describe physical properties about a body fluid as noted above. Not to be used to record the details about examination of faeces - use the CLUSTER.examination_faeces.
PurposeFor recording the findings observed during the examination of body fluid at a body site or from an identified body source, usually as part of a physical examination by a clinician.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2015-06-25
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2015-06-25
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, current_contact=Heather Leslie, Ocean Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=E63836086D870CF45F167306195BF6EB, build_uid=09a39b0e-ce1b-4a8c-b645-7b4037b2b0ae, revision=0.0.1-alpha}
Keywordsbiofluid, amniotic, blood, plasma, cerebrospinal, fluid, discharge, urine, pus, saliva, sputum, synovial, sweat, vomit, gastric, diarrhoea, mucous, mucus, spinal, bile, breast, milk, gastric, acid, semen, secretion, ascites, serous, intraocular, diasylate, synovial, bodily, pericardial, pleural
Lifecyclein_development
UID3e27076b-d1db-4a36-87db-17457bf10f46
Language useden
Citeable Identifier1013.1.2255
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the examination of body fluid at a body site or from an identified body source, usually as part of a physical examination by a clinician., archetypeConceptComment=null, otherContributors=Morten Aas, Oslo Universitetssykehus, Norway
Kerstin Adolfsson, Sweden
Stine Nyheim Andreassen, DIPS ASA, Norway
Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (Nasjonal IKT redaktør)
Kristian Berg, Universitetssykehuset Nord Norge, Norway
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Kate Bryan, Stalis Ltd, United Kingdom
David Burns, East Kent Hospitals University Foundation NHS Trust, United Kingdom
B Christensen, HUS, Norway
Peter Coates, NHS England, United Kingdom
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Heather Grain, Llewelyn Grain Informatics, Australia
Kristian Heldal, Telemark Hospital Trust, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Tom Jarl Jakobsen, Helse Bergen, Norway
Lars Karlsen, DIPS ASA, Norway
Dave Kilroy, Application Insight Ltd, United Kingdom
Shinji Kobayashi, Kyoto University, Japan
Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Ocean Informatics, Australia (openEHR Editor)
Siv Marie Lien, DIPS ASA, Norway
Kelvin Lok, Stalis Ltd, United Kingdom
Ole Kristian Losvik, Losol AS, Norway
Mark McEvoy, SITS International, Sweden
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Lars Ivar Mehlum, Helse Bergen HF, Norway
Colin Newell, OpusVL, United Kingdom
Andrej Orel, Marand d.o.o., Slovenia
Rob Organ, Yeovil District Hospital NHS Foundation Trust, United Kingdom
Petra Palm, Region Östergötland, Sweden
Mike Pargeter, Across Health Ltd, United Kingdom
Martin Paulson, Sykehuset i Vestfold, Norway
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
John Pyle, self, United Kingdom
Navin Ramachandran, NHS, United Kingdom
Cecilia Revelj, Landstinget i Kalmar län, Sweden
Ingela Sammeli, Landstinget i Värmland, Sweden
Elin Tell, Region Ostergotland, Sweden
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Lina Öfverström, Region Östergötland, Sweden, originalLanguage=en, translators=Norwegian Bokmål: Kristian Berg, John Tore Valand, Helse Nord, Helse Vest
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